Outpatient Surgery: The Doctor is In; The Patient is Out

An increasing percentage of surgeries are being performed on an outpatient basis at local hospitals and ambulatory centers, thanks to advancements in surgical techniques and pain management – a “win-win-win” for patients, hospitals and insurance providers alike.

Dr. Barry Barnes performs outpatient surgery at FHN in Freeport. About 75 percent of elective surgeries there are performed on an outpatient basis.

Few trends in U.S. medical practice have been as dramatic as the shift toward outpatient surgeries.

Along with routine procedures, such as tonsillectomies, appendectomies, gall bladder and cataract removal, many other surgeries now require patients to be in a hospital for one day or less. The benefits are significant, for hospitals, insurance providers and patients alike. Hospitals and surgeons find scheduling to be easier; most patients find recuperation to be more restful at home; surgical site infections are fewer; and the financial cost to everyone is lower, making elective surgeries more accessible to more people.

In dollars and cents, outpatient (also called ambulatory) surgery is about one-fifth the cost of equivalent inpatient surgery, according to the “Hospital-Based Ambulatory Surgery 2007” report by the Healthcare Cost & Utilization Project, a federal/state/industry partnership that shares data collection. The report analyzed costs of all surgeries performed in 28 states in 2007. The mean cost was $6,100 for outpatient, versus $39,000 for equivalent inpatient surgeries; nearly 58 percent of hospital surgeries performed that year were outpatient, and the number has grown each year since.

Northern Illinois and southern Wisconsin are no exception to this trend.

“When I began working at the hospital 38 years ago, about 16 percent of all surgical procedures were outpatient,” says Shirley Fischer, Beloit Health System’s director of surgical and ambulatory services. “Now the percentage of ambulatory surgeries is between 60 and 70. The difference begins with advances in medical technology and anesthesia. But it doesn’t stop there.”

Fischer began her career as an operating room (OR) staff nurse in 1973, later serving as director of surgery for nearly seven years. She moved to Quality Improvement for 15 years and returned to the OR in 2001. The improvements that have occurred during her career both astound and please her.

Christine Javurek, RN, works on a COW (computer on wheels) in the Outpatient Surgery Department of SwedishAmerican Hospital.

“It’s safe for patients to go home, because of the intensive pre-op and follow-up the hospital does to ensure that they’re doing well,” Fischer says. “If they have all the practical help they need, such as transportation and assistance at home, it’s amazing how well they do.”

Fischer cites cataract surgeries as an example of the progress of outpatient practices. The procedure once took up to an hour to perform, and patients spent up to a week in the hospital, their heads immobilized during much of that time. Today, most cataract patients are in and out of the hospital in less than half a day.

“Beloit Health System launched a new process in cataract removal that takes about 10 minutes,” says Fischer. “Patients are in the surgical center for a maximum of three hours.”

Patient feedback about shorter hospital stays is overwhelmingly positive. “Nationally, outpatient surgeries score between 94 and 98 percent in patient satisfaction,” says Fischer. “That’s huge, considering how the numbers have increased. It’s comforting to know our patients appreciate the outpatient surgical services. Everyone appreciates being able to go home and get well, but it’s especially good for children to be with their parents.”

Other common outpatient procedures include knee arthroscopic surgeries and cartilage repairs that don’t require incisions. Anterior cruciate ligament repair, which repairs trauma commonly incurred by athletes, is also performed on outpatients. Kidney stone removal, gynecological procedures such as D&Cs and minor bone fracture repairs are routinely performed on outpatients at Beloit Memorial, as well.

“In fact, we do almost 4,000 ambulatory procedures in a year,” says Fischer. “The biggest change I’ve seen lately is rotator cuff repairs. The surgeries are minimally invasive, with less trauma to tissue and muscle, and have a much lower chance of infection. Patients lose less work.”

Fischer explains that the surgical calendar has always been problematic, but is easier to maintain now, with greater convenience to patients and surgeons. With strict standards for safety, highly-trained staff and surgeons, and the latest equipment, there’s every reason to believe each outpatient will have a good outcome, she says.

Outpatient surgeries cost about one-fifth as much as equivalent inpatient surgeries, according to one national study. Here, Dr. Lisa Reinike performs an outpatient surgery at Beloit Memorial Hosptial.

In Rockford, outpatient service is increasing at SwedishAmerican Hospital’s surgical center, both in numbers of patients and scope of procedures. Ann Gantzer, chief nursing officer and vice president of nursing, outpatient services, has seen this trend advance tremendously during her 30-year career.

“I can remember the days when gall bladder patients spent 10 days, on average, in the hospital,” Gantzer says. “Now, they go home the next day, or in some cases, the same day as the surgery. The same is true of many gynecological operations, resulting in a hospital stay of only one or two days. The trend has evolved steadily over the past 15 years, as technology and medicine have improved and advanced. ”

At SwedishAmerican, surgeries are scheduled through the perioperative department. Pre-operation screening for outpatients depends on whether local, general or limited anesthesia will be used.

“We use an algorithm to determine what testing is ordered, based on the patient’s history and which procedure will be done,” Gantzer explains. “Patients come into the surgical center and, depending on what they present with, we do a pre-op work-up with appropriate tests. This is not a cookie-cutter approach but is tailored to each patient.”

“We see pediatric patients who need tubes in their ears, and others who need the full surgical service for open-heart and neurological surgeries,” says Tamara Bloom, nursing manager for outpatient surgery and recovery. “Outpatients receive the same thorough treatment as those who expect to be in the hospital to recover. But only patients who are going home come to me.”

The surgery itself is just one part of the healing experience SwedishAmerican offers to patients and their families.

“I believe we are unique in that we provide massage therapy for patients waiting to go into surgery,” Bloom says. “We also offer aromatherapy, deep breathing exercises, guided imagery and relaxation techniques, both pre- and post-op, as needed, to reduce stress and pain.”

Last year, SwedishAmerican introduced therapy dogs into the surgical waiting room. They provide family members with a soothing distraction from the anxiety that naturally occurs while waiting for loved ones to return from their surgeries.

Outpatient services don’t end when patients are released from the hospital. Follow-up calls are made to see how patients are doing, if their pain levels are acceptable and whether or not they have become ill at home. This also gives Bloom’s staff a chance to gather feedback about the entire surgical experience.

“In the near future, we’ll be initiating a fast-track program,” says Mary Jane O’Connor, RN, director of perioperative services at SwedishAmerican. “This will enable patients to go through the process even more quickly.”

About 75 percent of elective surgeries are outpatient at FHN in Freeport, says Dr. Barry B. Barnes, MD, FACS, recent chair of the surgical department. “They’re done either at the hospital or in ambulatory surgical centers, with the patients going home the same day,” he says. “Or, if they’re scheduled for a hospital stay, they come directly in for surgery without the usual pre-op process.”

FHN services range from the “bread-and-butter,” such as thoracic, gall bladder, hernia, minor breast, ENT and other soft tissue procedures, to major operations requiring hospital stays, such as serious head and neck procedures, bowel reconstruction and orthopedic surgeries. FHN also performs a wide range of state-of-the-art laparoscopic surgeries.

As a general surgeon, Barnes primarily performs hernia, gall bladder and some minor vascular procedures for outpatients, and breast and bowel surgeries for inpatients. He believes the advancements in outpatient technologies are safer overall and allow patients to recover in the comfort of their homes, with less risk of hospital-based infections. They also offer lower out-of-pocket costs.

When it opened 17 years ago, Rockford Ambulatory became the region’s first free-standing, multi-specialty outpatient surgical facility.

“There are a lot of benefits,” Barnes adds. “And while I don’t foresee major surgeries being done on outpatients in the near future, I do believe inpatient hospital stays will continue to become shorter, with patients going home an average of three to five days after surgery.”

Minimally-invasive techniques and expansion of robotic capabilities are supporting this trend.

The growing demand for outpatient services isn’t a recent development; the first U.S. ambulatory surgery center opened in 1972. On the leading edge of the emerging trend was Rockford Ambulatory Surgery Center, one of just 1,500 outpatient facilities nationwide when it performed its first procedure in September 1994. Today, there are more than 6,000.

“Patients like Rockford Ambulatory because it’s state-of the-art and they’re able to return home following their procedures,” says Dr. George Arends, medical director. “In the 17 years we’ve been in operation, we’ve rarely transferred patients to the hospital because of complications. This is a reflection of the quality of care provided by the surgeons on staff, and the pre-operative screening performed by our nurses.”

Arends says the center, at 1016 Featherstone Road, was the region’s first multi-specialty, free-standing facility dedicated exclusively to performing outpatient surgical services. Today it offers patients a wide range of elective surgical procedures including orthopedic, gynecological, ophthalmological, cosmetic, urological and podiatric. It also offers general and ENT surgeries and pain management.
Arends notes that the surgical site infection rate at Rockford Ambulatory is only 0.1 percent, compared to a national average of 2 to 3 percent for inpatient hospital stays.

Since opening, the center has performed about 70,000 procedures, though the volume has dropped slightly in recent years.

While it’s unlikely that major procedures such as organ transplants, joint replacements, open heart, brain, cancer and traumatic injury surgeries will be ever be performed on an outpatient basis, the future will doubtless bring more advances to the ever-changing face of health care. Such advances are already impacting costs in a positive manner, making elective surgeries more accessible to more people. ❚

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